Pelvic Organ Prolapse

The position of women’s pelvic organs may change over time. Pregnancy and childbirth, heavy lifting, coughing, or straining with bowel movements may cause pelvic support problems. Pelvic support problems can result in a hernia into the vagina. As a result women may feel pelvic pressure or heaviness. The may feel like "something is falling out of the vagina."

The organs that may be involved in pelvic organ prolapse include the bladder, urethra (the tube that empties the bladder), intestines, uterus, rectum, and the vagina itself. The bladder and the urethra are in front of the vagina. The uterus is at the top. The intestines are at the top and back of the vagina. The rectum is in back of the vagina. These structures are held in place by layers of connective tissue, ligaments, and pelvic floor muscles. When the support tissue become stretched, damaged, or weak the organ that they support may drop down and push on the wall of the vagina. This is the hernia. Sometimes the organ drop so much, the bulge created with the vaginal wall sticks out through the vaginal opening.

The hernia that is created is given a name based on the organ that is dropping down:

• Cystocele when the bladder is part of the hernia
• Rectocele when the rectum is part of the hernia
• Enterocele when the intestines are part of the hernia
• Uterine Prolapse when the uterus is part of the hernia
• Vault Prolapse when the top of the vagina is part of the hernia in someone that has previously undergone hysterectomy

Cystocele

A cystocele occurs on the anterior or front wall of the vagina when the bladder drops into the vagina. Some cystoceles can cause urinary leakage. Some cystoceles can make it difficult for a woman to empty her bladder. Some women are only able to empty their bladder by reaching into the vagina and pushing the bladder up with their fingers. Some women never completely empty their bladders due to cystocele. Women that do not empty their bladder completely can be at risk for recurrent bladder and kidney infections. Some cystoceles do not cause any problems or discomfort. If you are having any of the above symptoms, you should contact your doctor.

Rectocele

A rectocele occurs on the posterior or back wall of the vagina when the rectum drops into the vagina. A large rectocele may make it difficult to have a bowel movement. Some women are only able to empty their colon by reaching into the vagina and pushing the rectum back in place with their fingers. If you are having rectocele symptoms, you should contact your doctor.

Enterocele

An enterocele occurs when support at the top and back of the vagina weakens. Symptoms of enterocele are usually pressure and discomfort.

Uterine and Vault Prolapse

The uterus may drop down into the vagina. After a woman has had a hysterectomy and small percentage may have the top of the vagina significantly drop down. Mild degrees of prolapse are common and do not require surgery if they do not cause symptoms. Women with significant uterine or vault prolapse may have a feeling of pelvic pressure or a pulling feeling in the pelvis and low back. The cervix may stick out of the vagina in severe cases. This may cause pain with sexual intercourse.

Diagnosis of Pelvic Organ Prolapse

Diagnosis of Prolapse can only occur with a physical exam. Diagnosis is not always simple because many other conditions can produce the symptoms of prolapse. When evaluating you for pelvic organ prolapse, a physician will take a medical history and do a thorough exam, including a vaginal and rectal exam. You may be examined while lying down, sitting, and standing. You may be asked to strain or cough, and your bladder function may be tested.

Treatment

Some women do not know that they have pelvic organ prolapse until their gynecologist tells them during a routine physical exam. These women generally do not need treatment if they have no symptoms. Some women find that mild symptoms can be relieved by changes in diet, keeping weight under control, not smoking, and avoiding heavy lifting and straining. Symptoms may also be reduced by performing pelvic floor exercises called Kegel Exercises. A pessary device may be helpful in some women. Others may need surgery, or be helped with medication.

Kegel Exercises

Kegel exercises strengthen your pelvic muscles that surround the urethra, vagina, and rectum. These muscles are like any other muscle in your body. Exercise can result in improved tone. To perform Kegel exercises:

• Pretend that you have a tampon in your vagina. Squeeze the muscles that would push the tampon up into your vagina. This movement pulls the vagina and rectum up and back.
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• Hold as long as you can, up to 10 seconds. You may notice that at first you cannot hold for longer than a couple seconds. As your muscles strengthen, you will be able to hold the squeeze longer.
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• Do this 10-20 times in a row 2-3 times a day.
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• Good places to do Kegels are in line at the grocery, while waiting in traffic, or while waiting in your doctor’s office.
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• Your doctor can check to see if you are performing Kegel exercises correctly.

After doing Kelgels consistently for 12 weeks, you may see improvement in bladder symptoms. Other exercises that may be helpful can be taught by a physical therapist.

Vaginal Pessaries

A pessary is a device made of silicone that fits into the vagina and holds dropping organs back in place. Your doctor can determine the right type and size of pessary for you by doing an exam and fitting you. You may have to try a few types to get a good fit. When a pessary is used, it must be removed, cleaned, and reinserted on a regular basis. If cleaning is not done, it may result in a foul-smelling discharge and sores in the vagina. When used correctly, many patients find they can use the pessary for years.

Surgery

Pelvic Organ Prolapse can be corrected with surgery. Surgery can be done through the vagina or through the abdomen. Your doctor can determine the correct surgery for you based on your physical exam.

Surgery may relieve only some of your symptoms caused by prolapse. During the surgery, the doctor will has to use the already weakened ligaments and connective tissue to repair your pelvic support. Synthetic materials may also be used in the repair and do improve the chance of lasting correction of the problem.

The factors that caused the pelvic organ prolapse may cause it to recur. After surgery you should control your weight, avoid constipation, not smoke, and avoid activities that put pressure on these muscles. Patients may especially want to delay repair until after childbearing is completed. There is still a chance with eliminating most or all of these factors that more surgery may be needed later.